Abstract
This chapter describes the symptoms, clinical and radiographic findings, as well as treatment options for rheumatoid arthritis and other inflammatory arthropathies.
11 Rheumatoid Arthritis and Other Inflammatory Arthropathies
I. Rheumatoid Arthritis
A. Clinical Stages
Stage 1 : Synovial membrane inflammation and swelling without deformity.
Stage 2: Cartilage damage and deformity that is passively correctable.
Stage 3: Muscle atrophy and fixed deformity.
Stage 4: Cessation of inflammatory process, formation of fibrous tissue, and/or bony fusion.
B. History and Physical Examination
1. History/Presentation
Morning stiffness in the joints.
Inability to extend the fingers.
Inability to make a full fist with swan neck deformity.
Involvement of multiple joints (usually the hands and feet) with relative sparing of distal interphalangeal (DIP) joints.
Wrist weakness and pain worsened by forearm rotation.
Common questions:
Prior rheumatologic diagnosis.
Duration of symptoms.
Type of onset (acute or insidious).
Other involved joints.
Medications for arthritis.
Ability to perform activities of daily living.
2. Physical Examination
Hand
Soft tissue swelling of proximal interphalangeal (PIP) and metacarpophalangeal (CMC) joints.
Volar subluxation of proximal phalanges.
Ulnar drift of fingers (at MCP joints).
Chronic synovitis leading to tendon ruptures.
Tendon sheath involvement—dorsal and volar aspects of wrist, volar surface of digits.
Intra-articular involvement.
Boutonniere deformity—flexed PIP joints and extended DIP joints with elongation or rupture of central slip.
Swan neck deformity—PIP hyperextension, DIP flexion with dorsal subluxation of lateral bands.
Subcutaneous rheumatoid nodules 1 —olecranon, extensor surface offorearms, dorsal aspect of hands, and palmar aspect of digits.
Sudden loss of finger extension or flexion indicates rupture, which typically progresses from ulnar to radial.
Differential diagnosis for tendon rupture—MCP joint dislocation, displacement of extensor tendons into valleys between metacarpal heads (sagittal band rupture), posterior interosseous nerve compression leading to paralysis of the common extensor muscle. 2
Wrist
Ulnar styloid, ulnar head, and scaphoid are often first to develop synovitis. o Caput ulna syndrome: 3
Destruction of ligamentous components leading to dorsal prominence of the distal ulna due to volar subluxation of the radius.
Volar subluxation of extensor carpi ulnaris (ECU).
Distal radial ulnar joint (DRUJ) instability.
Limited wrist dorsiflexion.
Radial deviation of wrist.
Risk of attrition or rupture of extensor digitorum communis (EDC) to small finger with or without ring finger.
Scaphoid instability.
Severe disease—volar dislocation of wrist, destruction ofcarpal bones, and radioulnar joint dissociation.
Mannerfelt syndrome 4
Scaphoid osteophytes in the carpal tunnel leading to attritional flexor pollicis longus (FPL) ruptures.
Weak or absent flexion of the thumb distal phalanx.
Treatment involves spur excision in addition to tendon transfer or graft.
C. Imaging
Plain posteroanterior (PA) and lateral radiographs: o Periarticular erosions.
Joint space narrowing.
Osteopenia in hand and wrist joints.
D. Management
1. Nonsurgical
Medical
Nonsteroidal anti-inflammatory drugs (NSAIDs). o Corticosteroids.
Nonbiologic disease modifying antirheumatic drugs (DMARDs)—methotrexate, leflunomide, sulfasalazine, and hydroxychloroquine.
Biologic DMARDs—TNF-α and IL-1 inhibitors (infliximab, etanercept, and adalimumab).
No consensus on when to hold DMARDs in perioperative period. 5
General recommendation is to hold for half-life of medication both preoperatively and postoperatively.
Hold biologic 1 week before and after surgery.
It is advisable to continue methotrexate postoperatively.
Splinting 6
PIP joint splint for mild Boutonniere deformity.
Working wrist splints.
Ulnar deviation splints.
Ring splint for swan neck deformity.
Hand therapy. 7
2. Surgical: Hand
Rheumatoid nodules—excise if symptomatic.
Tenosynovitis—intra-tendon nodules may cause triggering, treat with tenosynovectomy preferably before tendon ruptures. 8
Tendon ruptures 9 , 10 : Extensor ruptures most common, proceeds from ulnar to radial:
Due to attrition at distal ulna, Lister’s tubercle, or scaphoid or due to tendon invasion by tenosynovium.
Extensor pollics longus (EPL) rupture:
Tendon transfers using extensor indicis proprius (EIP) (preferred), extensor carpi radialis longus (ECRL), or extensor digiti minimi (EDM).
Tendon grafting.
Finger extensor rupture
Direct repair.
Suture distal stump to adjacent extensor.
Tendon grafting from palmaris longus, ECRL, or extensor carpi radialis brevis (ECRB).
Tendon transfer using EIP to extensor digiti quinti (EDQ) for single small finger extensor rupture.
Tendon transfers using EIP for double ruptures.
Tendon transfers using flexor digitorum superficialis (FDS) for triple ruptures.
FPL rupture
Most common flexor tendon rupture.
Tendon graft—palmaris longus, slip of flexor carpi radialis (FCR) or abductor pollicis longus (APL).
Tendon transfer—ring finger FDS.
Flexor digitorum profundus (FDP) rupture
Palm or wrist level—suture distal tendon to adjacent tendon.
Remove diseased synovium from intact superficial flexor.
FDS rupture
Suture to adjacent tendons.
Tenosynovectomy to protect FDP tendons.
o FDP and FDS rupture
Suture to adjacent tendons.
Bridge graft to reconstruct FDP using FDS.
Fuse DIP and PIP joints.
Synovectomy and removal of bone spurs as part of surgery for any rupture.
Sagittal band ruptures
May lead to subluxation or dislocation ofextensor tendon.
Radial band most common.
Present with pain when extending MCP joint against resistance and pseudotriggering.
Treatment
Extension splinting for acute injuries.
Direct repair.
Reconstruction using strips of EDC or lumbrical transfer to EDC.
MCP joint deformity
Arthroplasty—silicone is standard. 11
Extensor tendon centralization.
Radial collateral ligament repair.
PIP joint deformity
Boutonniere deformity—synovectomy, extensor reconstruction, fusion, and/or arthroplasty.
Joints are generally surgically addressed in a proximal to distal direction (e.g., correct wrist before fingers).
Related posts:
6 Fractures, Dislocations, and Ligament Injuries of the Hand
8 Fractures and Dislocations of the Distal Radius and Ulna
12 Tendinitis, Tendinosis, and Dupuytren’s Contracture
15 Extensor Tendon Injury, Repair, and Reconstruction
20 Vascular Pathology of the Hand and Upper Extremities, including Kienbock’s Disease
25 Fractures of the Pediatric Hand
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